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病历摘要:患者女性,44岁,因气急三个月近一周来加重于1977年2月16日入院。患者于三月前开始经常夜间气急,有时须端坐方略缓解,近一周来更形加重,自诉伴心悸、尿少、及下肢略有浮肿。七月前曾有全身浮肿史,服药后即好转。过去经常易感冒。其他无特殊。体格检查:体温38.5℃,脉搏100次/分,呼吸34次/分,血压150/90毫米汞柱,神清,一般情况尚可,可以平卧、无青紫、皮肤粘膜无出血点及皮疹,两侧颈静脉无怒张,心律齐,心率100次/分,心尖区未闻及杂音,心界似向左下扩大,两肺呼吸音粗糙,无罗音。肝肋下2厘米,剑下约3厘米左右,质软,稍有压痛,四肢无浮肿。
Medical record summary: The patient female, 44 years old, due to shortness of breath for nearly three months a week to aggravate the admission on February 16, 1977. The patient started to have frequent nocturnal breathlessness before March, and sometimes he had to take a soothing approach. He had been exacerbated in the past week, complaining of heart palpitations, oliguria, and slight swelling of his lower limbs. There was a history of systemic edema before July, which improved after taking the medicine. In the past often easy to cold. No other special. Physical examination: body temperature 38.5 ℃, pulse 100 beats / min, breathing 34 beats / min, blood pressure 150/90 mm Hg, Shen Qing, the general situation is acceptable, supine, no bruising, skin and mucous membrane without bleeding and rash, Jugular vein on both sides without raging, rhythm Qi, heart rate 100 beats / min, the apical area did not smell and noise, the heart seems to expand to the left, rough breath sounds of both lungs, no rales. Liver ribs 2 cm, about 3 cm under the sword, soft, slightly tender, swollen limbs.